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ACP HospitalistWeekly 4-22-09
Highlights
- Alerts help prevent symptomatic VTE, study finds
- Study finds no association between admission glucose and mortality in patients with heart failure
Cardiology
- New scoring tool helps stratify bleeding risk in NSTEMI patients
- "Add-on" therapy may be useful in advanced decompensated heart failure
FDA update
- Influend Cough and Cold products recalled
- Patients older than 28 days can use ceftriaxone with calcium
From ACP Hospitalist
- Suggest a colleague as a Top Hospitalist
From ACP Internist
- Tweet the meet: Twittering from Internal Medicine 2009
Cartoon caption contest
- Vote for your favorite entry
Physician editor: A. Scott Keller, MD
Note: ACP members will receive daily updates from Internal Medicine 2009 in Philadelphia April 23-25. ACP HospitalistWeekly will not publish on April 29.
Highlights
.Alerts help prevent symptomatic VTE, study finds
Physicians who received alerts from staff members about hospitalized patients at high risk for symptomatic venous thromboembolism (VTE) were more likely to initiate prophylaxis, although the system was less effective than electronic alerts, a new study found.
In the study, published online April 13 in Circulation, researchers randomized 2,493 patients at 25 sites to an intervention group, in which attending physicians received alerts from staff members, or a control group in which physicians received no alerts. The patients, 82% of whom were on medical services, were enrolled based on a validated point score system to detect those at high risk for symptomatic VTE who were not receiving prophylaxis.
Patients in the intervention group were more than twice as likely to receive VTE prophylaxis as control group patients (46.0% vs. 20.6%; P< 0.0001) and the symptomatic VTE rate was lower, although not statistically significant, in the intervention group (2.7% vs. 3.4%; hazard ratio, 0.79; 95% CI, 0.50 to 1.25). The rate of major bleeding after 30 days did not differ significantly between groups. Despite guidelines supporting the use of VTE prophylaxis in high-risk patients, this study suggests that it is still underused, researchers noted, as patients in the intervention group received VTE prophylaxis less than half of the time (compared with less than one-quarter of the time in the control group).
Researchers also noted that their previous study of electronic alerts resulted in a 41% reduction in symptomatic VTE, compared with a 21% reduction in the current study, suggesting that computer-based systems work better than human reminders. This is despite the fact that prophylaxis was ordered more often with staff alerts than electronic alerts (46% vs. 33%). Researchers theorized that electronic alerts may be more effective because they are harder to ignore and have the advantage of providing direct access to decision support tools, such as evidence-based guidelines.
.Study finds no association between admission glucose and mortality in patients with heart failure
A large study of elderly patients hospitalized with heart failure found no significant association between elevated glucose levels at admission and mortality, whether or not patients had diabetes.
In the study, published in the April 14 Circulation, researchers evaluated more than 50,000 elderly patients hospitalized with heart failure between 1998-2001 and analyzed the association between admission glucose and all-cause mortality using multivariable Cox regression models. They found no significant relationship between glucose and 30-day or one-year mortality, even though the hyperglycemic heart failure patients had more severe heart failure on admission. Results did not differ between patients with or without diabetes.
The results demonstrate that the strong association between glucose and increased mortality risk seen in patients with acute myocardial infarction may not extend to patients with heart failure, the authors noted. They stressed that more disease-specific study on the relationship between glucose and patient outcomes may be needed before hospitals devote substantial resources to glycemic management strategies for all patients.
Cardiology
.New scoring tool helps stratify bleeding risk in NSTEMI patients
A new scoring tool helps determine the risk for in-hospital major bleeding among patients with non-ST-segment elevation myocardial infarction (NSTEMI), according to a study in the April 14 Circulation.
Researchers used data from over 89,000 patients in the CRUSADE study to develop and validate a model to stratify NSTEMI patients according to their bleeding risk. They found that admission values of hematocrit less than 36%, estimated creatinine clearance, heart rate, systolic blood pressure, signs of congestive heart failure, female sex, previous vascular disease, and diabetes mellitus were all independent predictors of major bleeding in this population. Major bleeding, which was previously shown to be associated with a five-fold increase in 30-day mortality, was defined as intracranial or retroperitoneal hemorrhage, an acute drop in hematocrit of at least 12%, any red cell transfusion when baseline hematocrit was at least 28%, or any red cell transfusion when the baseline hematocrit was less than 28% with a witnessed bleed.
The researchers assigned weighted integers to each predictor according to its coefficient in the regression model to develop the CRUSADE bleeding score. As the score increased, so did the major bleeding rates: 3.1% for those at very low risk (a score of 20 or less), 5.5% for those at low risk (a score of 21 to 30), 8.6% for those at moderate risk (a score of 31 to 40), 11.9% for those at high risk (a score of 41 to 50), and 19.5% for those at very high risk (a score over 50 (P< 0.001 for trend). Although they excluded patients who died within 48 hours of hospitalization or who were taking warfarin before admission, and they did not include data on previous bleeding or bleeding diathesis, the authors concluded that their study offers an effective tool to help clinicians assess and treat patients with NSTEMI. A bleeding score calculator is available online.
."Add-on" therapy may be useful in advanced decompensated heart failure
Isosorbide dinitrate and hydralazine may improve hemodynamic profiles and outcomes in patients with low-output advanced decompensated heart failure when added to traditional agents such as angiotensin-converting enzyme (ACE) inhibitors, a new study suggests.
Researchers performed a retrospective study of consecutive chronic systolic heart failure patients (NYHA class III to IV) at the Cleveland Clinic who received intensive medical therapy for advanced decompensated heart failure and were subsequently discharged between Jan. 1, 2003 and Dec. 31, 2006. The goal of the study was to determine whether adding isosorbide dinitrate and hydralazine to ACE inhibitors and angiotensin receptor blockers (ARBs) at discharge improved hemodynamic profiles and outcomes. The results appear in the April 15 American Journal of Cardiology.
Ninety-seven patients in the control group (ACE inhibitors and ARBs only) and 142 patients in the intervention group (ACE inhibitors and ARBs plus isosorbide dinitrate and/or hydralazine) were included in the analysis. Patients in both groups had similar blood pressure at hospital discharge and similar decreases in intracardiac filling pressures. However, those in the intervention group had greater improvement in cardiac index and systemic vascular resistance, as well as lower rates of all-cause mortality (34% vs. 41%; odds ratio, 0.65 [95% CI, 0.43 to 0.99]; P= 0.04) and all-cause mortality combined with rehospitalization for heart failure (70% vs. 85%; odds ratio, 0.72 [95% CI, 0.54 to 0.97]; P= 0.03). Patients were followed for a mean duration of 26.3 months after the index hospital admission.
The authors noted that their study was limited by its retrospective design and the fact that it was conducted in an intensive care unit dedicated to heart failure patients. However, they concluded that isosorbide dinitrate and hydralazine can improve hemodynamic profiles and outcomes in patients with advanced decompensated heart failure when added to standard therapy, despite similar systemic blood pressure targets. The authors called for a controlled trial to evaluate this finding before these results are translated into routine clinical practice.
FDA update
.Influend Cough and Cold products recalled
ION Labs, Inc. is recalling Influend Cough and Cold products sold on or after May 30, 2008 because they may be more potent than intended, the FDA said last week.
Complications from the recalled products could include tachycardia, palpitations, arrhythmias, cardiovascular collapse with hypotension, dizziness, anxiety, restlessness, and nervousness. No illnesses have been reported to date.
Products affected by the recall, which were distributed and sold directly to consumers in the Madison/Huntsville, Ala., area, include the 24-tablet Influend Cold and Cough (Lot# 800074) and Influend Severe Cold & Flu (Lot# 800075), and the 4-oz bottle of Influend JR. Cold & Cough (Lot# 800076) and Influend JR. Severe Cold & Flu (Lot# 800077).
.Patients older than 28 days can use ceftriaxone with calcium
Ceftriaxone (Rocephin) can be used concomitantly with intravenous calcium-containing products in patients older than 28 days, the FDA said last week in an update.
The FDA had warned physicians in 2007 against administering calcium-containing products and ceftriaxone within 48 hours of each other due to a risk for precipitation of ceftriaxone-calcium. Based on the results of two in vitro studies conducted by manufacturer Roche, the agency has now determined this risk is low in patients more than 28 days old.
Ceftriaxone should still not be used in neonates 28 days of age or younger if they are receiving, or are expected to receive, calcium-containing intravenous products. In patients older than this, the two products may be administered sequentially, as long as the infusion lines are thoroughly flushed between infusions with a compatible fluid, the FDA said. However, ceftriaxone must not be administered simultaneously with intravenous calcium-containing solutions via a Y-site in any age group.
From ACP Hospitalist
.Suggest a colleague as a Top Hospitalist
ACP Hospitalist is seeking candidates for our second annual Top Hospitalists issue. We're looking for the hospitalists who made notable contributions to the field in 2009, whether through cost savings, improved work flow, patient safety, leadership, mentorship or quality improvement.
Do you know a colleague who might qualify? Fill out our form and tell us who and why. All recommendations must be received by July 13, 2009, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2009 issue.
From ACP Internist
.Tweet the meet: Twittering from Internal Medicine 2009
ACP will Twitter from Internal Medicine 2009. Join us at http://twitter.com/ACPinternists. And Vineet Arora, FACP, will use her Twitter feed to digest events from Internal Medicine 2009. Using the alias @FutureDocs, she usually sends tweets about medical education for students and residents. Subscribe, or check out her Twitter page.
Cartoon caption contest
.Vote for your favorite entry
Our cartoon caption contest continues. ACP staff has selected three finalists for the latest contest and is now asking readers to vote for their favorite caption to determine the winner.
Go online to view the cartoon and pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues until April 24, with the winner announced in the Saturday edition of Internal Medicine News at ACP's annual meeting.
About ACP HospitalistWeekly
ACP HospitalistWeekly is a weekly newsletter produced by the staff of ACP Hospitalist. Please forward any comments or suggestions to acphospitalist@acponline.org.
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Copyright 2009 by the American College of Physicians.
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